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Protective roles of SIRT1 in atherosclerosis

Sokrates Stein & Christian M. Matter
Published online: 15 Feb 2011.

To cite this article: Sokrates Stein & Christian M. Matter (2011) Protective roles of SIRT1 in atherosclerosis , Cell Cycle, 10:4,
640-647, DOI: 10.4161/cc.10.4.14863

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 review

Cell Cycle 10:4, 640-647; February 15, 2011; © 2011 Landes Bioscience

Protective roles of SIRT1 in atherosclerosis

Sokrates Stein and Christian M. Matter
Cardiovascular Research; Institute of Physiology; Zurich Center for Integrative Human Physiology (ZIHP); University of Zurich; Zurich, Switzerland;
and Division of Cardiology; Cardiovascular Center; University Hospital Zurich; Zurich, Switzerland

Key words: sirtuin, SIRT1, atherosclerosis, thrombosis, inflammation, NFkB

Abbreviations: EC, endothelial cell; eNOS, endothelial nitric oxide synthase; HAEC, human aortic endothelial cell; ICAM-1,
intercellular adhesion molecule 1; LDL, low-density lipoprotein; Lox-1, lectin-like oxidized LDL receptor 1 (also called Olr1);
LXRα/β, liver x receptor; NAD, nicotinamide adenine dinucleotide; NAM, nicotinamide; NFκB, nuclear factor kappaB;
NO, nitric oxide; oxLDL, oxidized LDL; PGC-1α, PPARγ coactivator 1α; PPARγ, peroxisome proliferator-activated receptor γ;
ROS, reactive oxygen species; SR-A, scavenger receptor A; SR-B, scavenger receptor B; SR-PSOX/CXCL16, scavenger receptor for
phosphatidylserine and oxidized lipoprotein/CXC chemokine ligand 16; TF, tissue factor (also called coagulation factor III or F3);
TIMP3, tissue inhibitor of metalloproteinase 3; TNF-α, tumor necrosis factor alpha; VCAM-1, vascular cell adhesion molecule 1;
VSMC, vascular smooth muscle cell
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SIRT1 is a NAD+-dependent class III histone deacetylase (HDAC) Sirtuins Deacetylate Nε-Lysines
that mediates the effects of caloric restriction on lifespan and
metabolic pathways in various organisms. It deacetylates both HDACs promote the deacetylation of acetyl-Nε-lysine residues
histone and non-histone proteins and targets proteins with and thereby affect functional properties of the target protein.1
diverse cellular and tissue functions. In the vasculature of rodent HDACs are discriminated into four families: classes I–IV. Class
models SIRT1 mediates vasodilatation via eNOS-derived nitric
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III HDACs are also called sirtuins. The mammalian sirtuin
oxide (NO) and scavenging reactive oxygen species (ROS). family consists of seven HDACs that share a conserved catalytic
Recent studies demonstrated further protective roles of SIRT1 core domain and are expressed ubiquitously.2 Sirtuins reverse
in vascular biology and atherosclerosis. In endothelial cells

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and macrophages SIRT1 has anti-inflammatory functions by
downregulating the expression of various pro-inflammatory
cytokines by interfering with the NFkB signaling pathway.
Deacetylation of RelA/p65-NFkB by SIRT1 in macrophages
also suppresses the expression of Lox-1, a scavenger receptor
for oxidized low-density lipoproteins (oxLDL), thereby
preventing macrophage foam cell formation. Moreover, SIRT1
has been shown to regulate the activity of Liver X-receptor
(LXR), thereby promoting ABCA1-driven reverse cholesterol
transport in plaque macrophages. Finally, SIRT1 suppresses the
expression of endothelial tissue factor (coagulation factor III)
and hence exerts anti-thrombotic properties. These findings
indicate atheroprotective effects of SIRT1 in atherogenesis
and highlight the need for translational research from
bench-to-bedside. Indeed, SIRT1 activators are available for
experimental research and undergo clinical testing. Taken
together, these studies suggest SIRT1 activation as a promising
therapeutic approach in atherosclerosis. Further studies are
necessary to better understand the exact role of SIRT1 in the
protagonist cells orchestrating atherogenesis and to identify
the specificity, target effects and putative off-target effects of
these promising SIRT1 activators.
Correspondence to: Sokrates Stein and Christian M. Matter;
Email: sokrates@access.uzh.ch and christian.matter@access.uzh.ch
Submitted: 01/11/11; Accepted: 01/19/11
DOI: 10.4161/cc.10.4.14863
Nε-lysine acetylations of their target proteins by hydrolyzing one
NAD + and releasing nicotinamide (NAM), a unique byproduct
called O-acetyl-ADP-ribose (OAADPr) and the deacetylated
substrate.3-5 Sir2, the yeast homolog of SIRT1, was discovered
as a factor necessary for the transcriptional silencing of the silent
mating-type loci and telomeric areas in yeast by inducing DNA
heterochromatization.6-8 Homologs are also found in many
other species such as Escherichia coli, Salmonella typhimurium,
Caenorhabditis elegans, Drosophila melanogaster, Mus musculus,
Macaca mulatta and Homo sapiens, highlighting the fact that the
Sir2 family is conserved from bacteria to humans.9-12
The finding that extra copies of Sir2 prolong the life span
of yeast, whereas Sir2 deficiency caused the opposite,13 drew the
attention of many scientists to the Sir2/sirtuin field. It was shown
that Sir2 is a NAD + -dependent histone deacetylase and that both
Sir2 and NAD + are required for calorie restriction-mediated life
span extension in yeast.14-17 These findings placed Sir2 into a cen-
tral position linking the metabolic state of a cell with the tran-
scriptional control of gene expression.
Sir2 homologs and Sir2 activators also regulate the life span
in Caenorhabditis elegans and Drosophila melanogaster,18-20 and
it was recently demonstrated that moderate calorie restriction
lowers the incidence of aging-related deaths in rhesus mon-
keys.21 Nevertheless, it remains unclear whether sirtuins are
directly involved in calorie restriction-mediated lifespan exten-
sion.22-25 On the other hand, the central role of SIRT1 as a
metabolic regulator remains undisputed. Indeed, the function
of many important proteins involved in metabolism is regu-
lated by SIRT1, including peroxisome proliferator-activated

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receptor γ (PPARγ), PPARγ coactivator 1α (PGC-1α), nuclear
factor κB (NFκB), Liver X receptor α (LXRα or Nr1h3)
and endothelial nitric oxide synthase (eNOS or NOS3).26-31
Interestingly, many of these molecules have been found to play
a direct or indirect role in atherogenesis.32-35 The main findings
regarding the direct function of SIRT1 in atherosclerosis will
be discussed below.
Laminar Shear Stress Induces SIRT1 Expression
Depending on the flow pattern in an artery, shear stress exerts
atheroprotective or atheroprone properties. While steady or pul-
satile laminar flow with a clear direction confers anti-atherogenic
effects by increasing the eNOS-derived NO bioavailability, a dis-
turbed turbulent flow is atheroprone by activating pro-inflam-
matory and proliferative signaling cascades as well as increasing
the level of ROS.36 Human umbilical vein endothelial cells
(HUVECs) exposed to laminar flow in vitro enhance the expres-
sion of AMPK and SIRT1 and display increased NAD + levels and
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SIRT1 activity. Consequently, AMPK-mediated eNOS phos-
phorylation primes eNOS for deacetylation by SIRT1, thereby
activating eNOS and inducing NO generation.37 Consistently,
expression of SIRT1 is higher in vessel areas under pulsatile flow
(thoracic aorta) than in areas under disturbed flow (aortic arch)
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in C57BL/6 mice.37
SIRT1 Improves Endothelial Function
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Loss of intact endothelial function over time may lead to chronic
endothelial dysfunction, which is an indicator of cardiovascu-
lar disease and an early step in atherogenesis.38 Excessive pro-
duction of oxidant stress, which is often observed in patients
with hypertension, hypercholesterolemia or diabetes, impairs
NO production and inactivates NO to form toxic peroxynitrite
(ONOO-).39 Peroxynitrite may ‘uncouple’ eNOS, which means
that its oxygen reduction capacity is uncoupled from NO syn-
thesis, thereby yielding a dysfunctional superoxide-generating
enzyme that enhances vascular oxidative stress.40 These and
several other consequences of impaired NO biosynthesis dete-
riorate endothelial function and induce sustained endothelial
inflammatory activation that contributes to the development of
atherosclerosis.38,41-43
Several reports proposed that SIRT1 improves endothelium-
dependent vascular function: as mentioned above, laminar shear
stress enhances SIRT1 activity and activates eNOS.37 SIRT1
activation by resveratrol suppresses angiotensin II type I recep-
tor (AT1R) expression in vascular smooth muscle cells (VSMCs),
hence preventing vessel contraction and blood pressure increase.44
SIRT1 deacetylates and activates eNOS in vitro and improves
vascular function in aortic rings ex vivo.27 Furthermore, endothe-
lial overexpression of SIRT1 prevents atherosclerosis by improv-
ing vascular function in atherosclerosis-prone ApoE-/- mice kept
on a high-fat diet.45 Conversely, organ chamber experiments
using aortic rings of ApoE-/- SIRT1+/+ and ApoE-/- SIRT1+/- mice
kept on a high-cholesterol diet, demonstrated no difference in
endothelium-dependent vascular function.46 Several reasons may
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explain this discrepancy: (1) Chen et al. elegantly show the syner-
gistic activation of eNOS by SIRT1 and AMPK. However, there
is no genetic evidence derived from SIRT1 knockout cells or
mice demonstrating that SIRT1 is essential to activate eNOS.37
Miyazaki used resveratrol to activate and nicotinamide to inhibit
SIRT1 function. Of note, resveratrol is not a direct activator of
SIRT1 and nicotinamide affects the function of several sirtuins
and other proteins.47-49 Again, no confirmatory genetic studies
were performed.44 Mattagajasingh overexpressed a dominant-
negative SIRT1 mutant in rat aortic rings ex vivo. The study
is well conducted, and it would be interesting to extend it to
functional in vivo assays using pharmacological approaches.27
Zhang et al. overexpressed the human SIRT1 gene in endothe-
lial cells of atherosclerotic mice, resulting in an increased eNOS
expression and improved vascular function, but eNOS activity
or phosphorylation was not assessed.45 Stein et al. used ApoE-/-
SIRT1+/+ and haploinsufficient ApoE-/- SIRT1+/- mice to analyze
the role of endogenous SIRT1 on vascular function. Although
the intact allele cannot compensate the lack of SIRT1 transcript
from the deficient allele in the haploinsufficient animals, the pos-
sibility that the single allele produces sufficient protein to regu-
late eNOS cannot be excluded.46 Therefore, further genetic and
pharmacological studies are necessary determine the impact of
SIRT1 activity on eNOS and endothelium-dependent vascular
function.50
SIRT1 Inhibits Endothelial Cell Activation
Cytokines (e.g., TNF-α and several interleukins) and constitu-
ents of modified lipoproteins (e.g., lysophosphatidyl choline)
enhance oxidative stress in endothelial cells, which in turn acti-
vates the NFκB signaling pathway. Activated NFκB migrates
into the nucleus and induces the expression of numerous genes,
including many pro-inflammatory genes such as P-Selectin,
ICAM-1 and VCAM-1.51,52 These endothelial cells are consid-
ered ‘activated’. In contrast, under physiological conditions aortic
endothelial cells do not express these adhesion molecules, except
for low constitutive levels of ICAM-1.53 Activated endothelial
cells that present these molecules and secrete them into the blood
stream may recruit and activate blood monocytes, which then
transmigrate into the arterial intima. This transmigration of
monocytes is stimulated by chemokines such as monocyte che-
moattractant protein-1 (MCP‑1), MCP-4, regulated on activa-
tion normal T-cell expressed and secreted (RANTES) and IL-8,
which bind to G protein-coupled receptors and are expressed by
various vascular cells.54
The role of SIRT1 in endothelial activation is less controversial
than in endothelial dysfunction. Studies form our lab and others
suggest that SIRT1 exerts anti-inflammatory effects in vascular
endothelial cells (Fig. 1).46,55-57 SIRT1 deacetylates RelA/p65 at
K310 and suppresses its binding to naked DNA in human aortic
endothelial cells (HAECs), therefore interfering with a crucial
step in NFκB signaling activation and reducing the expression of
endothelial adhesion molecules.46 AcK310 deacetylation of RelA/
p65 by SIRT1 has also been observed in human epithelial lung
cells, myeloid cells and microglia.30,58,59 Importantly, suppression
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Figure 1. SIRT1 prevents endothelial adhesion molecule expression by suppressing the NFκB signaling pathway. Inflammatory stimuli such as TNF-α
or oxLDL lead to activation of endothelial cells, which in turn activate inflammatory signaling cascades and induce the expression of adhesion mol-
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ecules, such as ICAM-1, VCAM-1 and P-Selectin. These adhesion molecules attract and bind to leucocytes, thereby promoting their transmigration into
the arterial intima. SIRT1 diminishes this inflammatory activation by suppressing the NFκB signaling pathway and hence reducing the expression of
adhesion molecules.
of NFκB signaling by SIRT1 also plays an anti-atherogenic role
in vivo: Intra peritoneal injection of lipopolysaccharide to boost
NFκB signaling leads to increased aortic endothelial expression
of ICAM-1 and VCAM-1 in ApoE-/- SIRT1+/- compared to ApoE‑/-
SIRT1+/+ mice.46
SIRT1 in Vascular Smooth Muscle Cells
Stabilizes Plaques
Vascular smooth muscle cells (VSCMs) compose the media of
intact arteries, but in atherogenesis VSMCs are also found in the
intima of atherosclerotic plaques. VSMC apoptosis contributes
to plaque destabilization, but on the other hand VSMCs are the
only vascular cells that express stabilizing matrix components of
the fibrous cap, thereby hindering plaque rupture. Stable plaques
have a high VSMC content, whereas unstable plaques contain
fewer VSMCs and more macrophages.60,61 Overexpression of
SIRT1 and nicotinamide phosphoribosyltransferase (Nampt) in
VSMCs increases SIRT1 activity, suppresses p21 and increases
the replicative lifespan by converting them into senescence-resis-
tant cells.62 The tissue inhibitor of metalloproteinase 3 (TIMP3)
is an important inhibitor of metalloproteinases, which digest
the extracellular matrix. SIRT1 silencing in VSMCs reduces
TIMP3 expression, while SIRT1 overexpression increases
TIMP3 promoter activity.63 These studies indicate that SIRT1
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exerts athero-protective functions in VSMCs by stabilizing
plaques.
While many studies show that SIRT1 can fine-tune the
expression RelA/p65 target genes by deacetylating RelA/p65 in
different cell lines, a recent study demonstrates that RelA/p65
binds to a consensus NFκB binding site at the SIRT1 promoter
and induces its expression in an inflammatory environment in
the rat aortic smooth muscle cell line A7r5.64 Enhanced SIRT1
expression under these conditions may act as a rescue mechanism
in response to inflammation.
SIRT1 Decreases Cholesterol Uptake and
Macrophage Foam Cell Formation
Infiltration of monocyte-derived macrophages into the suben-
dothelial space is a key step in atherogenesis. These invading
macrophages release and respond to inflammatory mediators
and interact with cytotoxic and helper T cells. While in vitro
incubation of monocytes or macrophages with native LDL does
not lead to cholesterol accumulation, incubation with modified
LDL leads to a quick accumulation of cholesterol.65 The active
uptake of modified LDL, mainly oxLDL, is mediated by scav-
enger receptors, including scavenger receptor A (SR-A), CD36,
Lectin-like oxLDL receptor 1 (Lox-1) and scavenger receptor for
phosphatidylserine and oxidized lipoprotein/CXC chemokine
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Figure 2. Macrophage SirT1 reduces inflammation, diminishes cholesterol uptake and promotes reverse cholesterol transport. Plaque macrophages
contribute to atherosclerotic disease progression by triggering an inflammatory environment, mediating macrophage foam cell formation and
necrotic core expansion. SirT1 suppresses NFκB signaling activation, thereby reducing the expression of inflammatory molecules such as TNF-α, IL-1β,

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IL-6 and MCP-1. SirT1 diminishes the expression of Lox-1, a receptor for oxLDL that promotes macrophage foam cell formation. Furthermore, SirT1
stimulates LXr-mediated ABCA1 expression and hence promotes reverse cholesterol transport that protects the cell from excessive cholesterol ac-
cumulation.

ligand 16 (SR-PSOX/CXCL16). Uncontrolled accumulation of SIRT1 Promotes Reverse Cholesterol Transport

modified LDL leads to the formation of lipid droplets and foam
cell formation.66
SIRT1 regulates both inflammatory processes and cholesterol
metabolism in macrophages (Fig. 2). SIRT1 suppresses the expres-
sion of the scavenger receptor Lox-1 in macrophages, reduces the
uptake of oxLDL and prevents macrophage foam cell formation.67
Bone marrow transplantation experiments confirmed that mac-
rophage-derived SIRT1 is crucial to prevent atherosclerosis.67 In
an inflammatory context, it prevents fatty acid-induced inflam-
mation,68 reduces the expression of many pro-inflammatory mol-
ecules such as TNF-α, MCP-1 and interleukins,59,69 modulates
insulin sensitivity,70 and diminishes cyclooxygenase 2 (COX-2)
expression and prostaglandin E2 (PGE2) secretion.71 Moreover,
SIRT1-deficient macrophages display NFκB hyperacetylation
resulting in enhanced expression of various pro-inflammatory
genes as well as increased accumulation of activated macrophages
in the liver and adipose tissue in mice fed a high-fat diet.59 Other
studies showed that macrophage-derived SIRT1 regulates the
expression of matrix metalloproteinases (MMP) and the MMP-
regulator TIMP3 under pathological conditions.63,72 These find-
ings suggest that SIRT1 does not only regulate the expression
of scavenger receptors cholesterol uptake and anti-inflammatory
events in macrophages; SIRT1 also diminishes the expression of
MMPs, thereby promoting plaque stability.
in Macrophages
Mammalian cells are unable to degrade the sterol ring of cho-
lesterol, and most excess sterols can only be eliminated from the
body by biliary excretion. Therefore, macrophages and other
cell types have to export cholesterol to extracellular acceptors,
mainly HDLs, for transport to the liver. This reverse cholesterol
transport involves many enzymes and receptors, such as liver X
receptors (LXRs) and their binding partners retinoid X receptor
(RXRs), peroxisome-proliferator activated receptors (PPARs),
the ATP-binding cassette (ABC) transporters ABCA1 and
ABCG1 as well as the scavenger receptor SR-BI. Dysfunctional
reverse cholesterol transport mechanisms may lead to excessive
accumulation of cholesterol in the cell and therefore stimulate
foam cell formation and disease progression.73
Li et al. demonstrated that SIRT1 directly deacetylates
and thereby regulates the transcriptional activity of LXRα, an
important regulator of lipid homeostasis and inflammation.31
Activation of LXRα leads to expression of ABCA1 that regulates
the efflux of cholesterol into pre-βHDL particles. Indeed, Li et al.
showed that cholesterol efflux from SIRT1+/+ is higher than from
SIRT1-/- peritoneal macrophages ex vivo (Fig. 2). Furthermore,
the authors reported that the SIRT1 inhibitor NAM inhibits
cholesterol efflux in the human monocytic cell line THP-1.31

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Figure 3. Endothelial SIRT1 suppresses NFκB signaling-mediated tissue factor expression and arterial thrombosis. Release of endothelial tissue factor
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into the blood during plaque rupture activates the coagulation cascade, leading to platelet activation and thrombus growth. By suppressing the NFκB
signaling pathway in endothelial cells, SIRT1 diminishes tissue factor expression and activation and prevents arterial thrombosis in mice.
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In contrast, no change in cholesterol efflux was observed in the
mouse macrophage cell line RAW 264.7 upon treatment with
the SIRT1 inhibitor splitomicin.67 The different inhibitors or cell
types that have been used may explain the controversial results.
Moreover, neither NAM nor splitomicin are solely specific for
SIRT1. NAM is an end-product inhibitor of the deacetylation
reaction mediated by the NAD + -dependent sirtuins,74 and there-
fore an inhibitor of all NAD + -dependent sirtuins and possibly
other enzymes. Splitomicin was identified as an inhibitor of the
Saccharomyces cerevisiae Sir2p.75 Although splitomicin shows
weak inhibitory potential towards human SIRT1,76,77 it has been
used by different groups to inhibit human or mouse SIRT1.78-81
Future studies using different specific SIRT1 inhibitors and acti-
vators as well as genetic approaches are necessary to clarify the
role of SIRT1 in cholesterol efflux in vivo.
SIRT1 Inhibits Endothelial Tissue Factor Expression
and Coagulation
Atherothrombosis is the primary cause of myocardial infarction
and stroke, which are the main causes of morbidity and mortality
in developed countries. The main trigger of thrombosis is rupture
of a vulnerable atherosclerotic plaque. Once an atherosclerotic
plaque ruptures, highly thrombogenic material attracts platelets
to the site of injury, thereby inducing platelet aggregation and
an increase of the nascent thrombus. Tissue factor (coagulation
factor III) is abundantly expressed by various cells in atheroscle-
rotic plaques and released into the blood during plaque rupture,
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thereby activating the coagulation cascade that will activate
platelets. Activated platelets then release the contents of granules,
which further promote platelet recruitment, adhesion, aggrega-
tion and activation.82
It was recently demonstrated that SIRT1 may prevent athero-
thrombosis by downregulating the endothelial expression of tis-
sue factor: Treatment of wild-type mice with the SIRT1 inhibitor
splitomicin in vivo enhanced tissue factor activity and markedly
reduced the time upon coagulation in a photochemical vascular
injury model (Fig. 3).83 In vitro, SIRT1 diminishes tissue factor
expression by deacetylating RelA/p65 and suppressing NFκB sig-
naling in HAECs. SIRT1 inhibition or siRNA-mediated SIRT1
silencing in HAECs stimulated with inflammatory mediators
increased tissue factor expression.83 Patients with atherosclero-
sis have elevated levels of tissue factor84 and even higher con-
centrations are measured in the area around the culprit lesion
in patients with unstable angina or acute myocardial infarction
compared to patients with stable angina.85,86 The recent findings
showing that SIRT1 reduces thrombosis highlight the need for
evaluating pharmacological SIRT1 activation in patients with
acute coronary syndromes.
Perspective
Many studies demonstrate that SIRT1 exhibits anti-inflammatory
properties both in vitro (e.g., fatty acid-induced inflammation), in
vivo (e.g., myeloid deletion, atherosclerosis, sustainment of nor-
mal immune function in knock-out mice) as well as in clinical
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Figure 4. Pharmacological SIRT1 activation may exert beneficial effects on atherosclerosis and thrombosis. Several metabolic and inflammatory

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events may enhance atherosclerosis, such as endothelial dysfunction, endothelial activation, macrophage foam cell formation, defective reverse cho-
lesterol transport (RCT) and increased tissue factor expression. Recent studies demonstrate that SIRT1 may prevent these dysfunctions to some extent.
Several of these effects are mediated via activation of eNOS in endothelial cells and LXR in macrophages as well as via suppression of NFκB signaling
activation in various plaque cells, including endothelial cells, macrophages and smooth muscle cells.

studies (e.g., patients with chronic obstructive pulmonary dis-
ease).46,59,67,68,83,87,88 These studies imply that SIRT1 activation
may be a promising strategy for treating chronic inflammatory
diseases, such as atherosclerosis and atherothrombosis (Fig. 4).
Indeed, several SIRT1 activators have been developed by SirtrisTM
Pharmaceuticals.89 While some studies claim that these activa-
tors are specific,90-92 others demonstrated that these compounds
do not act via direct SIRT1 activation.93 According to SirtrisTM
Pharmaceuticals new SIRT1-activating drugs are being developed
and tested in phase IIa clinical trials in patients with type 2 diabe-
tes, inflammation and cardiovascular disease. Future studies will
be necessary to better understand the SIRT1 specificity, clinical
5.
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Acknowledgements
This work was supported by grants from the Swiss National
Science Foundation 31-114094/1, 310030_130626/1 and the
University Research Priority Program “Integrative Human
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